External lumbar drainage in the ICU
Update and guidelines for the clinical handling
Keywords:
EXTERNAL LUMBAR DRAINAGE, SUBARACHNOID HEMORRHAGE, CEREBROSPINAL FLUID DRAINAGE, INTRACRANIAL HYPERTENSION
Abstract
The placement of an external lumbar drainage (ELD), an invasive procedure to extract cerebrospinal fluid (CSF) from the spinal space, has gradually increased in practice in recent years within the context of neurocritical medicine. Despite it not being recommended by international guidelines or consensus, it is used for the handling of a few specific clinical situations in connection with different types of severe brain injury. The study consists of a non-systematic review of the literature, along with the authors’ experience, presenting the main current indications and details for its handling in the different clinical scenarios and describing side effects and complications of the procedure.
References
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(2) Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal J Neurosurg 2017;126(1): 289-297.
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(4) Aldave G, Hansen D, Briceño V, Luerssen TG, Jea A. Assessing residents’ operative skills for external ventricular drain placement and shunt surgery in pediatric neurosurgery. J Neurosurg Pediatr 2017 19: 377–383.
(5) Cushing H. Some aspects of the pathological physiology of intracranial tumors. Boston Med Surg J 1909; 141:71–80
(6) Hepburn H. The risk of spinal puncture. Can Med Assoc J 1938; 39:449–450.
(7) Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80(1): 6-15.
(8) Hawryluk GWJ, Aguilera S, Buki A, Bulger E, Citerio G, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2019; 45(12): 1783-1794.
(9) Kochanek PM, Tasker RC, Carney N, Totten AM et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines Pediatr Crit Care Med 2019; 20 (3S Suppl 1): S1-S82.
(10) Korein J, Cravioto H, Leicach M. Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension. Neurology 1959; 9(4): 290-7.
(11) Baldwin HZ, Rekate HL. Preliminary experience with controlled external lumbar drainage in diffuse pediatric head injury. Pediatr Neurosurg 1991; 17(3):115–120.
(12) Levy DI, Rekate HL, Cherny WB, Manwaring K, Moss SD, Baldwin HZ. Controlled lumbar drainage in pediatric head injury. J Neurosurg 1995; 83: 453-460.
(13) Rekate HL. Hyperemic hydrocephalus. J Neurosurg Pediatrics 2010; 5: 17-19.
(14) Klimo PJr, Kestle JRW, MacDonald JD, Schmidr RH. Marked reduction of cerebral vasospasm with lumbar drainage of CSF after subarachnoid hemorrhage. J Neurosurg 2004; 100:215-24.
(15) Wolf S. Rationale for lumbar drains in aneurysmal subarachnoid hemorrhage. Curr Opin Crit Care 2015, 21: 120-126.
(16) Fisher CM, Kistler JP, Davis M. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computed tomographic scanning. Neurosurgery 1980; 6: 1-9.
(17) Maeda Y, Shirao S, Yoneda H, Ishihara H, Shinoyama M, Oka F, et al. Comparison of lumbar drainage and external ventricular drainage for clearance of subarachnoid clots after Guglielmi detachable coil embolization for aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2013; 115 (7): 965-70.
(18) Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJP, Quinn AC, et al. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke 2012; 43:677-82.
(19) Fang Y, Shao Y, Lu J, Dong X, Zhao X, Zhang J, et al. The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts. Neurosurg Rev 2020; 43(2):739-47.
(20) Kwon OY, Kim Y-J, Kim YJ, Cho CS, Lee SK, Cho MK. The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2008; 43:281-7.
(21) Borkar SA. 183 spinal cerebrospinal fluid drainage for prevention of vasospasm in aneurysmal subarachnoid haemorrhage: a prospective randomized controlled study. Neurosurgery 2013; 60(Suppl 1):180-1.
(22) Hanggi D, Eicker S, Beseoglu K, Behr J, Turowski B, Steiger H-J. A multimodal concept in patients after severe aneurysmal subarachnoid hemorrhage: results of a controlled single centre prospective randomized multimodal phase I/II trial on cerebral vasospasm. Cent Eur Neurosurg 2009; 70:61-7.
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(24) Qian C, Yu X, Chen J, Gu C, Wang L, Chen G, et al. Effect of drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a meta-analysis. Medicine (Baltimore) 2016; 95(41):e5140.
(25) Bardutzky J, Witsch J, Juttler E, Schwab S, Vajkoczy P, Wolf S. EARLYDRAIN – outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial. Trials 2011; 12:203.
(26) Mu¨nch EC, Bauhuf C, Horn P, Roth HR, Schmiedek P, Vajkoczy P. Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage. Crit Care Med 2001; 29(5):976-81.
(27) Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C, et al. Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. J Neurosurg 2009; 110(6):1200-8.
(28) Murad A, Ghostine S, Colohan ART. Controlled lumbar drainage in medically refractory increased intracranial pressure. A safe and effective treatment. Acta Neurochir Suppl 2008; 102:89-91.
(29) Murad A, Ghostine S, Colohan AR. Role of controlled lumbar CSF drainage for ICP control in aneurysmal SAH. Acta Neurochir Suppl 2011; 110(Pt 2):183-7.
(30) Llompart-Pou JA, Abadal JM, Pérez-Bárcena J, Molina M, Brell M, Ibáñez J, et al. Long-term follow-up of patients with post-traumatic refractory high intracranial pressure treated with lumbar drainage. Anaesth Intensive Care 2011; 39(1):79-83.
(31) Akil H. The treatment of refractory intracranial hypertension and its control by means of external lumbar drainage (ELD). J Trauma 2007; 63(3):720-1.
(32) Abadal-Centellas JM, Llompart-Pou JA, Homar-Ramírez J, Pérez-Bárcena J, Rosselló-Ferrer A, Ibáñez-Juvé J. Neurologic outcome of posttraumatic refractory intracranial hypertension treated with external lumbar drainage. J Trauma 2007; 62(2):282-6.
(33) Cardoso ER, Schubert R. External hydrocephalus in adults. Report of three cases. J Neurosurg 1996; 85(6):1143-7.
(34) Manet R, Schmidt EA, Vassal F, Charier D, Gergelé L. CSF lumbar drainage: a safe surgical option in refractory intracranial hypertension associated with acute posttraumatic external hydrocephalus. Acta Neurochir Suppl 2016; 122: 55-9.
(35) Manet R, Payen JF, Guerin R, Martinez O, Hautefeuille S, Francony G, Gergelé L. Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury. Acta Neurochir (Wien) 2017; 159(10):2003-9.
(36) Huh PW, Yoo DS, Cho KS, Park CK, Kang SG, Park YS, et al. Diagnostic method for differentiating external hydrocephalus from simple subdural hygroma. J Neurosurg 2006; 105(1):65-70.
(37) Rekate HL, Nadkarni TD, Wallace D. The importance of the cortical subarachnoid space in understanding hydrocephalus. J Neurosurg Pediatr 2008; 2(1):1-11.
(38) Spertell RB. On the transmission of external pressure fluctuations to the cerebrospinal fluid. J Theor Biol 1981; 88(2):309-21.
(39) Denning DW, Armstrong RW, Lewis BH, Stevens DA. Elevated cerebrospinal fluid pressures in patients with cryptococcal meningitis and acquired immunodeficiency syndrome. Am J Med 1991; 91:267-72.
(40) Macsween KF, Bicanic T, Brouwer AE, Marsh H, Macallan DC, Harrison TS. Lumbar drainage for control of raised cerebrospinal fluid pressure in cryptococcal meningitis: case report and review. J Infect 2005; 51:e221-4.
(41) Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infec Dis 2010; 50:291-322.
(42) Manosuthi W, Sungkanuparph S, Chottanapund S, Tansuphaswadikul S, Chimsuntorn S, Limpanadusadee P, et al. Temporary external lumbar drainage for reducing elevated intracranial pressure in HIV-infected patients with cryptococcal meningitis. Int J STD AIDS 2008; 19:268-71.
(43) Calvo A, Hernández P, Spagnuolo E, Johnston E. Surgical treatment of intracranial hypertension in encephalic cryptococcosis. Br J Neurosurg 2003; 17(5):450-5.
(44) Buth J, Harris PL, Hobo R, van Eps R, Cuypers P, Duijm L, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007; 46:1103-10.
(45) Riambau V. How to decrease Spinal Cord Ischemia (SCI) and stroke after TEVAR: how to perform CSF drainage optimally. En: 38th Annual VEITHsymposium on Vascular Disease Management. New York, NY: 16-20 nov. 2011.
(46) Cinà CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg 2004; 40:36-44.
(47) Coselli JS, Lemaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002; 35:631-9.
(48) Bauer M, Sohm F, Thomé C, Ortler M. Refractory intracranial hypertension in traumatic brain injury: proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage. Surg Neurol Int 2017; 8:265.
(49) Linsler S, Schmidtke M, Steudel WI, Kiefer M, Oertel J. Automated intracranial pressure-controlled cerebrospinal fluid external drainage with LiquoGuard. Acta Neurochir (Wien) 2013; 155(8):1589-94.
(50) Staykov D, Speck V, Volbers B, Wagner I, Saake M, Doerfler A, et al. Early recognition of lumbar overdrainage by lumboventricular pressure gradient. Neurosurgery 2011; 68:1187-91.
(51) Komotar RJ, Mocco J, Ransom ER, Mack WJ, Zacharia BE, Wilson DA, et al. Herniation secondary to critical postcraniotomy cerebrospinal fluid hipovolemia. Neurosurgery 2005; 57(2):286-92.
(52) Wang K, Liu Z, Chen X, Chen X, Lou M, Yin J. Clinical characteristics and outcomes of patients with cerebral herniation during continuous lumbar drainage. Turk Neurosurg 2013; 23:653-7.
(53) Champey J, Mourey C, Francony G, Pavese P, Gay E, Gergele L, et al. Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study. J Neurosurg 2018; 1-6. doi:10.3171/2018.1.JNS172486.
(2) Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal J Neurosurg 2017;126(1): 289-297.
(3) Grille P, Costa G, Biestro A, Wajskopf S. Manejo del drenaje ventricular externo en la UCI. Guía práctica de consenso. Rev Med Urug 2007; 23: 50- 55.
(4) Aldave G, Hansen D, Briceño V, Luerssen TG, Jea A. Assessing residents’ operative skills for external ventricular drain placement and shunt surgery in pediatric neurosurgery. J Neurosurg Pediatr 2017 19: 377–383.
(5) Cushing H. Some aspects of the pathological physiology of intracranial tumors. Boston Med Surg J 1909; 141:71–80
(6) Hepburn H. The risk of spinal puncture. Can Med Assoc J 1938; 39:449–450.
(7) Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80(1): 6-15.
(8) Hawryluk GWJ, Aguilera S, Buki A, Bulger E, Citerio G, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2019; 45(12): 1783-1794.
(9) Kochanek PM, Tasker RC, Carney N, Totten AM et al. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines Pediatr Crit Care Med 2019; 20 (3S Suppl 1): S1-S82.
(10) Korein J, Cravioto H, Leicach M. Reevaluation of lumbar puncture; a study of 129 patients with papilledema or intracranial hypertension. Neurology 1959; 9(4): 290-7.
(11) Baldwin HZ, Rekate HL. Preliminary experience with controlled external lumbar drainage in diffuse pediatric head injury. Pediatr Neurosurg 1991; 17(3):115–120.
(12) Levy DI, Rekate HL, Cherny WB, Manwaring K, Moss SD, Baldwin HZ. Controlled lumbar drainage in pediatric head injury. J Neurosurg 1995; 83: 453-460.
(13) Rekate HL. Hyperemic hydrocephalus. J Neurosurg Pediatrics 2010; 5: 17-19.
(14) Klimo PJr, Kestle JRW, MacDonald JD, Schmidr RH. Marked reduction of cerebral vasospasm with lumbar drainage of CSF after subarachnoid hemorrhage. J Neurosurg 2004; 100:215-24.
(15) Wolf S. Rationale for lumbar drains in aneurysmal subarachnoid hemorrhage. Curr Opin Crit Care 2015, 21: 120-126.
(16) Fisher CM, Kistler JP, Davis M. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computed tomographic scanning. Neurosurgery 1980; 6: 1-9.
(17) Maeda Y, Shirao S, Yoneda H, Ishihara H, Shinoyama M, Oka F, et al. Comparison of lumbar drainage and external ventricular drainage for clearance of subarachnoid clots after Guglielmi detachable coil embolization for aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2013; 115 (7): 965-70.
(18) Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJP, Quinn AC, et al. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke 2012; 43:677-82.
(19) Fang Y, Shao Y, Lu J, Dong X, Zhao X, Zhang J, et al. The effectiveness of lumbar cerebrospinal fluid drainage in aneurysmal subarachnoid hemorrhage with different bleeding amounts. Neurosurg Rev 2020; 43(2):739-47.
(20) Kwon OY, Kim Y-J, Kim YJ, Cho CS, Lee SK, Cho MK. The utility and benefits of external lumbar CSF drainage after endovascular coiling on aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2008; 43:281-7.
(21) Borkar SA. 183 spinal cerebrospinal fluid drainage for prevention of vasospasm in aneurysmal subarachnoid haemorrhage: a prospective randomized controlled study. Neurosurgery 2013; 60(Suppl 1):180-1.
(22) Hanggi D, Eicker S, Beseoglu K, Behr J, Turowski B, Steiger H-J. A multimodal concept in patients after severe aneurysmal subarachnoid hemorrhage: results of a controlled single centre prospective randomized multimodal phase I/II trial on cerebral vasospasm. Cent Eur Neurosurg 2009; 70:61-7.
(23) Alcalá-Cerra G, Paternina-Caicedoa A, Díaz-Becerraa C, Moscote-Salazar LR, Gutiérrez-Paternina JJ, Niño-Hernándeza LM. Drenaje lumbar externo de líquido cefalorraquídeo en pacientes con hemorragia subaracnoidea aneurismática: revisión sistemática y metaanálisis de estudios controlados. Neurología 2014; 31(7):431-44.
(24) Qian C, Yu X, Chen J, Gu C, Wang L, Chen G, et al. Effect of drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a meta-analysis. Medicine (Baltimore) 2016; 95(41):e5140.
(25) Bardutzky J, Witsch J, Juttler E, Schwab S, Vajkoczy P, Wolf S. EARLYDRAIN – outcome after early lumbar CSF-drainage in aneurysmal subarachnoid hemorrhage: study protocol for a randomized controlled trial. Trials 2011; 12:203.
(26) Mu¨nch EC, Bauhuf C, Horn P, Roth HR, Schmiedek P, Vajkoczy P. Therapy of malignant intracranial hypertension by controlled lumbar cerebrospinal fluid drainage. Crit Care Med 2001; 29(5):976-81.
(27) Tuettenberg J, Czabanka M, Horn P, Woitzik J, Barth M, Thomé C, et al. Clinical evaluation of the safety and efficacy of lumbar cerebrospinal fluid drainage for the treatment of refractory increased intracranial pressure. J Neurosurg 2009; 110(6):1200-8.
(28) Murad A, Ghostine S, Colohan ART. Controlled lumbar drainage in medically refractory increased intracranial pressure. A safe and effective treatment. Acta Neurochir Suppl 2008; 102:89-91.
(29) Murad A, Ghostine S, Colohan AR. Role of controlled lumbar CSF drainage for ICP control in aneurysmal SAH. Acta Neurochir Suppl 2011; 110(Pt 2):183-7.
(30) Llompart-Pou JA, Abadal JM, Pérez-Bárcena J, Molina M, Brell M, Ibáñez J, et al. Long-term follow-up of patients with post-traumatic refractory high intracranial pressure treated with lumbar drainage. Anaesth Intensive Care 2011; 39(1):79-83.
(31) Akil H. The treatment of refractory intracranial hypertension and its control by means of external lumbar drainage (ELD). J Trauma 2007; 63(3):720-1.
(32) Abadal-Centellas JM, Llompart-Pou JA, Homar-Ramírez J, Pérez-Bárcena J, Rosselló-Ferrer A, Ibáñez-Juvé J. Neurologic outcome of posttraumatic refractory intracranial hypertension treated with external lumbar drainage. J Trauma 2007; 62(2):282-6.
(33) Cardoso ER, Schubert R. External hydrocephalus in adults. Report of three cases. J Neurosurg 1996; 85(6):1143-7.
(34) Manet R, Schmidt EA, Vassal F, Charier D, Gergelé L. CSF lumbar drainage: a safe surgical option in refractory intracranial hypertension associated with acute posttraumatic external hydrocephalus. Acta Neurochir Suppl 2016; 122: 55-9.
(35) Manet R, Payen JF, Guerin R, Martinez O, Hautefeuille S, Francony G, Gergelé L. Using external lumbar CSF drainage to treat communicating external hydrocephalus in adult patients after acute traumatic or non-traumatic brain injury. Acta Neurochir (Wien) 2017; 159(10):2003-9.
(36) Huh PW, Yoo DS, Cho KS, Park CK, Kang SG, Park YS, et al. Diagnostic method for differentiating external hydrocephalus from simple subdural hygroma. J Neurosurg 2006; 105(1):65-70.
(37) Rekate HL, Nadkarni TD, Wallace D. The importance of the cortical subarachnoid space in understanding hydrocephalus. J Neurosurg Pediatr 2008; 2(1):1-11.
(38) Spertell RB. On the transmission of external pressure fluctuations to the cerebrospinal fluid. J Theor Biol 1981; 88(2):309-21.
(39) Denning DW, Armstrong RW, Lewis BH, Stevens DA. Elevated cerebrospinal fluid pressures in patients with cryptococcal meningitis and acquired immunodeficiency syndrome. Am J Med 1991; 91:267-72.
(40) Macsween KF, Bicanic T, Brouwer AE, Marsh H, Macallan DC, Harrison TS. Lumbar drainage for control of raised cerebrospinal fluid pressure in cryptococcal meningitis: case report and review. J Infect 2005; 51:e221-4.
(41) Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, et al. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the Infectious Diseases Society of America. Clin Infec Dis 2010; 50:291-322.
(42) Manosuthi W, Sungkanuparph S, Chottanapund S, Tansuphaswadikul S, Chimsuntorn S, Limpanadusadee P, et al. Temporary external lumbar drainage for reducing elevated intracranial pressure in HIV-infected patients with cryptococcal meningitis. Int J STD AIDS 2008; 19:268-71.
(43) Calvo A, Hernández P, Spagnuolo E, Johnston E. Surgical treatment of intracranial hypertension in encephalic cryptococcosis. Br J Neurosurg 2003; 17(5):450-5.
(44) Buth J, Harris PL, Hobo R, van Eps R, Cuypers P, Duijm L, et al. Neurologic complications associated with endovascular repair of thoracic aortic pathology: incidence and risk factors. A study from the European Collaborators on Stent/Graft Techniques for Aortic Aneurysm Repair (EUROSTAR) registry. J Vasc Surg 2007; 46:1103-10.
(45) Riambau V. How to decrease Spinal Cord Ischemia (SCI) and stroke after TEVAR: how to perform CSF drainage optimally. En: 38th Annual VEITHsymposium on Vascular Disease Management. New York, NY: 16-20 nov. 2011.
(46) Cinà CS, Abouzahr L, Arena GO, Laganà A, Devereaux PJ, Farrokhyar F. Cerebrospinal fluid drainage to prevent paraplegia during thoracic and thoracoabdominal aortic aneurysm surgery: a systematic review and meta-analysis. J Vasc Surg 2004; 40:36-44.
(47) Coselli JS, Lemaire SA, Köksoy C, Schmittling ZC, Curling PE. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002; 35:631-9.
(48) Bauer M, Sohm F, Thomé C, Ortler M. Refractory intracranial hypertension in traumatic brain injury: proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage. Surg Neurol Int 2017; 8:265.
(49) Linsler S, Schmidtke M, Steudel WI, Kiefer M, Oertel J. Automated intracranial pressure-controlled cerebrospinal fluid external drainage with LiquoGuard. Acta Neurochir (Wien) 2013; 155(8):1589-94.
(50) Staykov D, Speck V, Volbers B, Wagner I, Saake M, Doerfler A, et al. Early recognition of lumbar overdrainage by lumboventricular pressure gradient. Neurosurgery 2011; 68:1187-91.
(51) Komotar RJ, Mocco J, Ransom ER, Mack WJ, Zacharia BE, Wilson DA, et al. Herniation secondary to critical postcraniotomy cerebrospinal fluid hipovolemia. Neurosurgery 2005; 57(2):286-92.
(52) Wang K, Liu Z, Chen X, Chen X, Lou M, Yin J. Clinical characteristics and outcomes of patients with cerebral herniation during continuous lumbar drainage. Turk Neurosurg 2013; 23:653-7.
(53) Champey J, Mourey C, Francony G, Pavese P, Gay E, Gergele L, et al. Strategies to reduce external ventricular drain-related infections: a multicenter retrospective study. J Neurosurg 2018; 1-6. doi:10.3171/2018.1.JNS172486.
Published
2020-12-01
How to Cite
1.
Grille P, Salle F, Biestro A. External lumbar drainage in the ICU. Rev. Méd. Urug. [Internet]. 2020Dec.1 [cited 2024Nov.24];36(4):401-10. Available from: https://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/646
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